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Transition in eye gaze as a predictor of emergence from general anesthesia in children and adults: a prospective observational study.

ABSTRACT:

Background

It is useful to monitor eye movements during general anesthesia, but few studies have examined neurological finding of the eyes during emergence from general anesthesia maintained with short-acting opioids and volatile anesthetics.

Methods

Thirty children aged 1-6 years and 30 adults aged 20-79 years were enrolled. Patients received general anesthesia maintained with sevoflurane and remifentanil. The timing of three physical-behavioral responses-eye-gaze transition (the cycle from conjugate to disconjugate and back to conjugate), resumption of somatic movement (limbs or body), and resumption of respiration-were recorded until spontaneous awakening. The primary outcome measure was the timing of the physical-behavioral responses. Secondary outcome measures were the incidence of eye-gaze transition, and the bispectral index, concentration of end-tidal sevoflurane, and heart rate at the timing of eye-gaze transition.

Results

Eye-gaze transition was evident in 29 children (96.7%; 95% confidence interval, 82.8-99.9). After the end of surgery, eye-gaze transition was observed significantly earlier than resumption of somatic movement or respiration (472 [standard deviation 219] s, 723 [235] s, and 754 [232] s, respectively; p < 0.001). In adults, 3 cases (10%; 95% CI, 0.2-26.5) showed eye-gaze transition during emergence from anesthesia. The incidence of eye-gaze transition was significantly lower in adults than in children (p < 0.001).

Conclusion

In children, eye-gaze transition was observed significantly earlier than other physical-behavioral responses during emergence from general anesthesia and seemed to reflect emergence from anesthesia. In contrast, observation of eye gaze was not a useful indicator of emergence from anesthesia in adults.

SUBMITTER: Kinoshita M

PROVIDER: S-EPMC9575208 | biostudies-literature | 2022 Oct

REPOSITORIES: biostudies-literature

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Transition in eye gaze as a predictor of emergence from general anesthesia in children and adults: a prospective observational study.

Kinoshita Michiko M Sakai Yoko Y Katome Kimiko K Matsumoto Tomomi T Sakurai Shizuka S Jinnouchi Yuka Y Tanaka Katsuya K

BMC anesthesiology 20221017 1

<h4>Background</h4>It is useful to monitor eye movements during general anesthesia, but few studies have examined neurological finding of the eyes during emergence from general anesthesia maintained with short-acting opioids and volatile anesthetics.<h4>Methods</h4>Thirty children aged 1-6 years and 30 adults aged 20-79 years were enrolled. Patients received general anesthesia maintained with sevoflurane and remifentanil. The timing of three physical-behavioral responses-eye-gaze transition (the ...[more]

PMID: 36253763

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Project description:Objective Emergence from anesthesia starts from the limbic structures and then spreads outwards to brainstem, reticular activating systems, and then to the cortex. Epilepsy surgery often involves resection of limbic structures and hence may disrupt the pattern of emergence. The aim of this study was to explore the pattern of emergence from anesthesia following epilepsy surgery and to determine associated variables affecting the emergence pattern. Setting and Design Tertiary care center, prospective observational study. Materials and Methods We conducted a prospective observation pilot study on adult patients undergoing anterior temporal lobectomy and amygdalohippocampectomy for epilepsy. Anesthesia management was standardized in all patients, and they were allowed to wake up with "no touch" technique. Primary outcome of the study was the pattern of emergence (normal emergence, agitated emergence, or slow emergence) from anesthesia. Secondary outcomes were to explore the differences in preoperative neuropsychological profile and limbic structure volumes between the different patterns of emergence. Quantitative variables were analyzed using Student's t -test. Qualitative variables were analyzed using chi-square test. Results Twenty-nine patients completed the study: 9 patients (31%) had agitated emergence, and 20 patients had normal emergence. Among the agitated emergence, 2 patients had Riker scale of 7 indicating violent emergence. Patient demographics, anesthetic used, neuropsychological profile, and limbic structure volumes were similar between normal emergence and agitated emergence groups. However, two patients who had severe agitation (Riker scale of 7) had the lowest intelligence quotient. Conclusion Our pilot study showed that emergence agitation is not uncommon in patients undergoing epilepsy surgery. However, due to smaller sample size, the role of preoperative neuropsychologic profile and hippocampal volumes in predicting the pattern of emergence is inconclusive.

Project description:BackgroundSevoflurane anesthesia is widely used in pediatric ambulatory surgery. However, emergency agitation (EA) and emergency delirium (ED), as major complications following sevoflurane anesthesia in children, pose risks to surgery and prognosis. Identifying the high risk of EA/ED, especially anesthesia exposure and the depth of anesthesia, may allow preemptive treatment.MethodsA total of 137 patients were prospectively enrolled in this single-center observational cohort study to assess the incidence of EA or ED. Multivariable logistic regression analyses were used to test the association between volatile anesthesia exposure and depth with EA or ED. The Richmond Agitation and Sedation Scale (RASS), Pediatric Anesthesia Emergence Delirium Scale (PAED) and Face, Legs, Activity, Cry, and Consolability (FLACC) behavioural pain scale was used to assess the severity of EA or ED severity and pain. Bispectral index (BIS) to monitor the depth of anesthesia, as well as TimeLOW-BIS/TimeANES %, EtSevo (%) and EtSevo-time AUC were included in the multivariate logistic regression model as independent variables to analyze their association with EA or ED.ResultsThe overall prevalence of EA and ED was 73/137 (53.3%) and 75/137 (54.7%) respectively, where 48/137 (35.0%), 19/137 (13.9%), and 6/137 (4.4%) had mild, moderate, and severe EA. When the recovery period was lengthened, the prevalence of ED and extent of FLACC decreased and finally normalized within 30 min in recovered period. Multivariable logistic regression demonstrated that intraoperative agitation [2.84 (1.08, 7.47) p = 0.034], peak FLACC [2.56 (1.70, 3.85) p < 0.001] and adverse event (respiratory complications) [0.03 (0.00, 0.29) p = 0.003] were independently associated with higher odds of EA. Taking EtSevo-time AUC ≤ 2,000 as a reference, the incidence of EA were [15.84 (2.15, 116.98) p = 0.002] times and 16.59 (2.42, 113.83) p = 0.009] times for EtSevo-time AUC 2,500-3,000 and EtSevo-time AUC > 3,000, respectively. Peak FLACC [3.46 (2.13, 5.62) p < 0.001] and intraoperative agitation [5.61 (1.99, 15.86) p = 0.001] were independently associated with higher odds of developing ED. EtSevo (%), intraoperative BIS value and the percentage of the duration of anesthesia at different depths of anesthesia (BIS ≤ 40, BIS ≤ 30, BIS ≤ 20) were not associated with EA and ED.ConclusionsFor pediatrics undergoing ambulatory surgery where sevoflurane anesthesia was administered, EA was associated with surgical time, peak FLACC, respiratory complications, and "EtSevo-time AUC" with a dose-response relationship; ED was associated with peak FLACC and intraoperative agitation.

Project description:BackgroundInadequate or excessive nociceptive control during general anesthesia can result in significant adverse outcomes. Using traditional clinical variables, such as heart rate, systolic blood pressure, and respiratory rate, to assess and manage nociceptive responses is often insufficient and could lead to overtreatment with both anesthetics and opioids. This study evaluated the feasibility and effectiveness of three nociception monitoring techniques Nociception Level Index (NOL), Skin Conductance Algesimeter (SCA) and heart rate monitoring in patients undergoing image-guided, minimally invasive abdominal interventions under general anesthesia.MethodThis prospective observational study collected data from 2022 to 2024. All patients were anesthetized according to the department's routine, and predetermined events were recorded. Two commercially available nociception monitors, the PMD-200 from Medasense (NOL) and PainSensor from MedStorm (SCA), were used, and their data were collected along with various hemodynamic parameters. The three nociception monitoring techniques were compared during predetermined events.ResultA total of 49 patients were included in this study. NOL and SCA demonstrated higher responsiveness than HR for all events except for skin incision. The comparison of the values above and below the threshold for each nociceptive stimulus showed significance for all measurements using the SCA and NOL. However, using HR as a surrogate for nociception with a threshold of a 10% increase from baseline, the difference was significant only at skin incision. There was no variation in the peak values attributable to differences in patients' age. Weight was a significant predictor of the peak NOL values.ConclusionNOL and SCA demonstrated superior sensitivity and responsiveness to nociceptive stimuli compared to HR, effectively detecting significant changes in nociceptive thresholds across various stimuli, although responses during skin incision showed no such advantage.Trial registrationClinical trial - NCT05218551.

Project description:BackgroundEmergence delirium can occur after general anesthesia in children. An intravenous infusion of alfentanil may reduce the incidence or severity of emergence delirium after sevoflurane anesthesia.ObjectiveThe study aimed to investigate the effects of alfentanil intravenous infusion on emergence delirium and other perioperative complications.MethodThis was a single-center, randomized, placebo-controlled, double-blind clinical trial. A total of 172 children undergoing ambulatory dental treatment were randomized into three groups. Alfentanil group Alf2 received 0.2 μg/kg/min of alfentanil for continuous infusion, alfentanil group Alf4 received 0.4 μg/kg/min alfentanil, and the saline group (group Sal) received a continuous infusion of normal saline, with the same volume as the two other groups, as a placebo. The incidence of emergence delirium (assessed by the Paediatric Anaesthesia Emergence Delirium [PAED] scale), hemodynamic parameters, and recovery characteristics were recorded during the recovery period. The Aono scale was also used to assess for emergence delirium. A WeChat applet was designed to facilitate a caregiver teleconsultation and to provide feedback on postoperative nausea and vomiting and any other complications after discharge.ResultsThe incidence of emergence delirium in group Alf2 (22.9%) and group Alf4 (21.1%) was significantly lower than that observed in the Sal group (48.3%). The PAED scores in group Alf2 (6.4 ± 3.5) and group Alf4 (5.8 ± 3.8) were significantly lower than those for group Sal (9.6 ± 5.1) (p < 0.01). Ten children in the Alf4 group needed manual ventilatory assistance to maintain end-tidal carbon dioxide (ETCO2) < 55 mm; children in group Alf2 did not. There was no significant difference between the discharge time of groups Alf2 and Sal (31.2 ± 4.64 vs 30.5 ± 2.82 min; 0.659 [95% confidence interval {CI} -1.052 to 2.369], p = 0.643); the time to discharge of group Alf4 (35.16 ± 3.97 min) was significantly longer than that of groups Alf2 and Sal (p < 0.01). The incidence of nausea and vomiting was similar in the three groups. No other clinically relevant adverse events were observed.ConclusionsIntravenous infusion of 0.2 μg/kg/min and 0.4 μg/kg/min alfentanil decreased the incidence of emergence delirium in the post-anesthesia care unit. The 0.2 μg/kg/min dose of alfentanil resulted in less respiratory depression and discharge delay than the 0.4 μg/kg/min alfentanil dose.Trial registrationChinese Clinical Trial Registry (ChiCTR2100043320).

Project description:PurposeTo determine the effect of general anesthesia on intraocular pressure (IOP) in children with no intraocular pathology and determine which postanesthetic time point is most predictive of preinduction IOP.DesignProspective observational study.ParticipantsChildren with no intraocular pathology ≤ 18 years scheduled for general anesthesia as part of their routine care followed by a pediatric ophthalmologist at Nanjing Medical University.MethodsParticipants underwent a standardized general anesthetic protocol using a mask induction with sevoflurane and propofol maintenance. Intraocular pressure was measured at the following 7 time points: preinduction (taken in the preoperative area), postinduction minutes 1, 3, and 5, and postairway placement minutes 1, 3, and 5 for a total time period of 10 minutes after induction. A generalized estimating equation was used to evaluate the effect of anesthesia on IOP and the effect of patient factors (age, gender, vital signs, and airway type) on preanesthetic and postanesthetic IOP. An IOP prediction model was developed using the postanesthesia IOP measurements for predicting preinduction IOP.Main outcome measuresIntraocular pressure and change in IOP at prespecified time points.ResultsEighty-five children were enrolled with a mean ± standard deviation (SD) age of 7.5 ± 2.9 years. Mean ± SD preinduction IOP was 20.1 ± 3.7 mmHg. Overall, IOP was lowest at 3 minutes postinduction, decreased to a mean of 13.4 ± 3.7 mmHg (P < 0.001). After this, IOP rose 5 minutes postinduction to 16.5 ± 4.2 mmHg, which did not reach preinduction IOP levels (P < 0.001). The IOP prediction model showed that combining 1 minute postinduction and 3 minutes postairway was most predictive (R2 = 0.13), whereas 1 minute postairway was least predictive of preinduction IOP (R2 = 0.01).ConclusionsAfter the induction of general anesthesia in children, IOP temporarily decreases with a trough at 3 minutes postinduction before increasing and remaining stable just below preinduction levels. Intraocular pressure measurements taken 1 minute after induction with 3 minutes after airway placement are most predictive of preinduction IOP, though predictive value is relatively low.Financial disclosuresProprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Project description:IntroductionThe potential adverse effects of prolonged exposure to anesthetics in pediatric patients with severe-to-profound sensorineural hearing loss remain unclear. This study aimed to examine whether early bilateral cochlear implantation involving long-duration anesthetic exposure caused greater developmental impairment than that with unilateral cochlear implantation.MethodsThis prospective observational study included normally developing infants with bilateral severe-to-profound sensorineural hearing loss aged 6 months to 2 years who were candidates for unilateral/bilateral cochlear implantation surgery. Baseline (T0), 6-month (T1), and 1-year (T2) Gesell Scale scores were measured. The outcomes included fine motor, adaptability, gross motor, language, and social skills scale 6 and 12 months postoperatively.ResultThe 90 enrolled children with bilateral severe-to-profound sensorineural hearing loss (unilateral n = 43; bilateral n = 47) had a younger bilateral group (11.00 ± 3.66 vs. 15.63 ± 6.99 months, p < .001). Anesthesia duration was longer in the bilateral group (271.57 ± 36.09 vs. 148.81 ± 25.60 min, p < .001). Gross motor, fine motor, adaptability, and language scores improved in both groups, and no significant between-group differences occurred in the fine motor scale at T1 and T2. Language developmental quotients improved significantly in the bilateral group compared with the unilateral group at T1 (mean differences: 25.07 ± 4.37 vs. 10.88 ± 4.61, p < .001) and T2 (mean differences: 34.98 ± 5.94 vs. 15.28 ± 6.55, p < .001). Stepwise regression revealed that gross motor, adaptability, language, and social skill developmental quotients at T1 were positively correlated with those at T0. Gross motor, fine motor, and social skill developmental quotients at T2 were negatively correlated with age at operation. Language developmental quotients were positively correlated with T0 values (p < .001) and in the bilateral group (p < .001) at T1 and T2.ConclusionsWhen evaluating young children with bilateral severe-to-profound sensorineural hearing loss, despite longer exposures to general anesthesia, bilateral cochlear implantations were associated with more improvement in language scores and no differences in other skills compared with those with only unilateral implantation.

Project description:BackgroundCerebral oxygen saturation (rSO2c) decrease from baseline greater than 20 % during infant cardiac surgery was associated with postoperative neurologic changes and neurodevelopmental impairment at 1 year of age. So far, there is no sufficient evidence to support the routine monitoring of rSO2c during general surgical procedures in children. We aimed to find out the frequency of cerebral desaturation 20 % or more from baseline and to identify possible predictors of change in cerebral oxygen saturation during neonatal and infant general surgery.MethodsForty-four infants up to 3 months of age were recruited. Before induction of anesthesia, two pediatric cerebral sensors were placed bilaterally to the forehead region and monitoring of regional cerebral saturation of oxygen was started and continued throughout the surgery. Simultaneously, mean arterial blood pressure (MAP), pulse oximetry (SpO2), heart rate (HR), endtidal CO2, expired fraction of sevoflurane and rectal temperature were recorded. The main outcome measure was rSO2c value drop-off ≥20 % from baseline. Mann-Whitney U-test, chi-squared test, simple and multiple linear regression models were used for statistical analysis.ResultsForty-three infants were analyzed. Drop-off ≥20 % in rSO2c from baseline occurred in 8 (18.6 %) patients. There were no differences in basal rSO2c, SpO2, HR, endtidal CO2, expired fraction of sevoflurane and rectal temperature between patients with and without desaturation 20 % or more from baseline. But the two groups differed with regard to gestation, preoperative mechanical ventilation and the use of vasoactive medications and red blood cell transfusions during surgery. Simple linear regression model showed, that gestation, age, preoperative mechanical ventilation and mean arterial pressure corresponding to minimal rSO2c value during anesthesia (MAPminrSO2c) were associated with a change in rSO2c values. Multiple regression model including all above mentioned variables, revealed that only MAPminrSO2c was predictive for a change in rSO2c values (β (95 % confidence interval) -0.28 (-0.52-(-0.04)) p = 0.02).ConclusionsCerebral oxygen desaturation ≥20 % from baseline occurred in almost one fifth of patients. Although different perioperative factors can predispose to cerebral oxygenation changes, arterial blood pressure seems to be the most important. Gestation as another possible risk factor needs further investigation.Trial registrationThe international registration number NCT02423369 . Retrospectively registered on April 2015.

Project description:Surgery patients in Japan undergo routine spirometry testing prior to general anesthesia. The use of a flow sensor during general anesthesia has recently become common. However, it is not certain whether the information derived from flow-volume curves is being adequately used for mechanical ventilation management during general anesthesia. So far, there have been no attempts to calculate airway resistance using flow-volume curves. Therefore, we performed a prospective, observational study to investigate the relationship between pre-anesthetic and intra-anesthetic airway resistance in patients scheduled for surgery under general anesthesia. We calculated pre-anesthetic and intra-anesthetic airway resistance in each patient, based on the slopes of flow-volume curves obtained prior to and during general anesthesia. We also calculated endotracheal tube resistance to correct the intra-anesthetic airway resistance values calculated. A total of 526 patients were included in the study, and 98 patients had a forced expiratory volume in the first second/forced vital capacity ratio of < 70%. Pre-anesthetic airway resistance was significantly higher in patients with airflow obstruction than in those without airflow obstruction (p < 0.001), whereas no significant difference in intra-anesthetic airway resistance was found between patients with and without airflow obstruction during mechanical ventilation (p = 0.48). Pre-anesthetic and intra-anesthetic airway resistance values were closer to each other in patients without airflow obstruction, with a mean difference < 1.0 cmH2O L-1s-1, than in those with airflow obstruction, although these respiratory parameters were significantly different (p < 0.001). Intra-anesthetic airway resistance was not related to the FEV1/FVC ratio, regardless of the degree to which the FEV1/FVC ratio reflected pre-anesthetic airway resistance. As compared with patients with airflow obstruction, the mean difference between pre-anesthetic and intra-anesthetic airway resistance was small in patients without airflow obstruction.

Dataset Information

Transition in eye gaze as a predictor of emergence from general anesthesia in children and adults: a prospective observational study.

Background

Methods

Results

Conclusion

Publications

Transition in eye gaze as a predictor of emergence from general anesthesia in children and adults: a prospective observational study.

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